Secondary Prevention Pharmacotherapy Research Articles

The impact of pharmacist-initiated interventions in improving acute coronary syndrome secondary prevention pharmacotherapy prescribing upon discharge

Pharmacists have the knowledge regarding optimal use of medications and the ability to influence physician prescribing. Successful interventions by a pharmacist to implement cardioprotective medications to a coronary artery disease patient's regimen would not only improve the patient's quality of care but may also increase his or her likelihood of survival. Therefore, the aim of this study was to (i) evaluate the effectiveness of pharmacist initiated interventions in increasing the prescription rates of acute coronary syndrome (ACS) secondary prevention pharmacotherapy at discharge, and to (ii) evaluate the acceptance rate of these interventions by prescribers. This was a comparative study with a pre-intervention and post-intervention design. In the pre-intervention phase, a retrospective cross-sectional audit was performed. Patients with a diagnosis of acute coronary syndrome admitted to the hospital in the period from 2008 to January 2010 were identified from medical records and served as a historical control. The second phase (intervention phase) was conducted from the beginning of March to the end of September 2010. Two random samples of 190 patients with ACS were included. During the intervention phase, two hospital pharmacists made rounds with the cardiology team and gave secondary prevention recommendations when needed. The major reference for the recommendations was the Malaysian guidelines. A total of 72 interventions were made by pharmacists of which drug initiation was most common (59.7%) followed by recommendations to change to another medication (23.6%) and optimization of medication dosing (16.6%). Most recommendations (72.2%) were accepted by prescribers. Majority of accepted recommendations were with β-blockers (38.46%) followed by those with angiotensin-converting-enzyme inhibitors (ACEI) (28.8%). The intervention had a significant impact on the utilization rates of β-blockers (increased from 75.8% to 84.7%, P=0.028), angiotensin-converting-enzyme inhibitors/angiotensin II receptor bockers (from 65.3% to 74.7%, P=0.044) and statins (from 91.6% to 98.4%, P=0.002). The intervention had also led to a significant increase in the utilization rates of all these four classes together (from 42.6% to 62.6%, P=0.001). The study showed that the presence of a pharmacist on cardiology units increased the use of beta-blockers, aspirin, and statins for the secondary prophylaxis of ACS.

Patients’ adherence to secondary prevention pharmacotherapy after acute coronary syndromes

Secondary prevention pharmacotherapy improves outcomes after acute coronary syndrome (ACS). However, poor medication adherence is common, and various factors play a role in adherence. The purpose of this study was to evaluate patients' level of adherence to evidence-based therapies at an average of 6 months after discharge for acs and to identify factors associated with self-reported non-adherence. This prospective study was conducted in the outpatient cardiac clinics of Hospital Pulau Pinang, located in Penang Island, a northern state in Malaysia. A random sample of ACS patients (n = 190) who had been discharged on a regimen of secondary preventive medications were included in this study. Six months after discharge and during their scheduled follow-up appointments to cardiac clinics, patients were interviewed using the translated eight-item Morisky Medication Adherence Scale. self-reported patients' adherence to medication. Six months following their hospital discharge, only 35 patients (18.4 %) reported high adherence. Medium adherence was reported in majority of patients (51.1 %). Low adherence was reported in 58 patients (30.5 %). Forgetfulness was the most frequently reported reason for patients' non-adherence to their medications (23.2 %). Furthermore, this study identified 5 factors-namely age, employment status, ACS subtypes, number of comorbidities, and number of prescription medications per day-that may influence Patients' level of adherence to the prescribed regimens. Our findings revealed a problem of non-adherence to secondary prevention medications among patients with ACS in Malaysia. Furthermore, this study demonstrates that older patients, unemployed patients, patients with more comorbid conditions, and those receiving multiple medications are less likely to adhere to their prescribed medications 6 months after hospital discharge.

Prognosis after percutaneous coronary intervention in patients with psoriasis: a cohort study using Danish nationwide registries

BackgroundPsoriasis is an inflammatory disease associated with increased risk of coronary artery disease. However, the potential impact of psoriasis on the prognosis following percutaneous coronary revascularization (PCI) is unknown.MethodsThe study comprised the entire Danish population undergoing first-time PCI in the period 2002–09. Cox regression models, controlling for age, gender, socioeconomic status, pharmacological treatment, and comorbidity were used to assess the risk of 1) all-cause mortality and 2) a composite endpoint of death, myocardial infarction, and stroke.ResultsA total of 53,141 patients with first-time PCI in the study period were identified. Of these, 1074 had mild psoriasis and 315 had severe psoriasis. Patients with severe psoriasis, but not those with mild disease had increased risk of both endpoints compared to patients without psoriasis. The incidence rates for all-cause mortality were 30.5 (CI 29.7-31.3), 29.9 (CI 24.7-36.1), and 47.2 (CI 35.0-63.6) per 1000 patient years for patients without psoriasis, with mild psoriasis, and with severe psoriasis, respectively. Hazard ratios were 1.10 (CI 0.91-1.33) and 1.67 (CI 1.24-2.26) for mild and severe psoriasis, respectively. Patients with severe psoriasis were less likely to receive secondary prevention pharmacotherapy with betablockers, statins and platelet inhibitors.ConclusionThis first study of the prognosis following PCI in patients with psoriasis demonstrated an increased risk of all-cause mortality and of a composite of death, myocardial infarction and stroke, respectively, in patients with severe psoriasis compared to patients without psoriasis. Further studies of this novel association are needed.

Initiation and adherence to secondary prevention pharmacotherapy after myocardial infarction in patients with rheumatoid arthritis: a nationwide cohort study

ObjectivesTo examine whether rheumatoid arthritis (RA) is associated with less optimal secondary prevention pharmacotherapy after first-time myocardial infarction (MI).MethodsThe authors identified all patients with first-time MI in the Danish National...

Almanac 2011: acute coronary syndromes. The national society journals present selected research that has driven recent advances in clinical cardiology

SUMMARY This overview highlights some recent advances in the epidemiology, diagnosis, risk stratification and treatment of acute coronary syndromes. The sheer volume of new studies reflects the robust state of global cardiovascular research but the focus here is on the findings that are of most interest to the practising cardiologist. Incidence and mortality rates for myocardial infarction are in decline, probably owing to a combination of lifestyle changes, particularly smoking cessation, and improved pharmacological and interventional treatment. Troponins remain central for diagnosis and new high-sensitivity assays are further lowering detection thresholds and improving outcomes. The incremental diagnostic value of other circulating biomarkers remains unclear and for risk stratification simple clinical algorithms such as the GRACE score have proved more useful. Primary PCI with minimal treatment delay is the most effective reperfusion strategy in ST elevation myocardial infarction (STEMI). Radial access is associated with less bleeding than with the femoral approach, but outcomes appear similar. Manual thrombectomy limits distal embolisation and infarct size while drug-eluting stents reduce the need for further revascularisation procedures. Non-culprit disease is best dealt with electively as a staged procedure after primary PCI has been completed. The development of antithrombotic and antiplatelet regimens for primary PCI continues to evolve, with new indications for fondaparinux and bivalirudin as well as small-molecule glycoprotein (GP) IIb/IIIa inhibitors. If timely primary PCI is unavailable, fibrinolytic treatment remains an option but a strategy of early angiographic assessment is recommended for all patients. Non-ST segment elevation myocardial infarction (NSTEMI) is now the dominant phenotype and outcomes after the acute phase are significantly worse than for STEMI. Many patients with NSTEMI remain undertreated and there is a large body of recent work seeking to define the most effective antithrombotic and antiplatelet regimens for this group of patients. The benefits of early invasive treatment for most patients are not in dispute but optimal timing remains unresolved. Cardiac rehabilitation is recommended for all patients with acute myocardial infarction but take-up rates are disappointing. Home-based programmes are effective and may be more acceptable for many patients. Evidence for the benefits of lifestyle modification and pharmacotherapy for secondary prevention continues to accumulate but the argument for omega-3 fatty acid supplements is now hard to sustain following recent negative trials. Implantable cardioverter-defibrillators for patients with severe myocardial infarction protect against sudden death but for primary prevention should be based on left ventricular ejection fraction measurements late (around 40 days) after presentation, earlier deployment showing no mortality benefit.

Almanac 2011: Acute coronary syndromes. The national society journals present selected research that has driven recent advances in clinical cardiology

SUMMARY This overview highlights some recent advances in the epidemiology, diagnosis, risk stratification and treatment of acute coronary syndromes. The sheer volume of new studies reflects the robust state of global cardiovascular research but the focus here is on the findings that are of most interest to the practising cardiologist. Incidence and mortality rates for myocardial infarction are in decline, probably owing to a combination of lifestyle changes, particularly smoking cessation, and improved pharmacological and interventional treatment. Troponins remain central for diagnosis and new high-sensitivity assays are further lowering detection thresholds and improving outcomes. The incremental diagnostic value of other circulating biomarkers remains unclear and for risk stratification simple clinical algorithms such as the GRACE score have proved more useful. Primary PCI with minimal treatment delay is the most effective reperfusion strategy in ST elevation myocardial infarction (STEMI). Radial access is associated with less bleeding than with the femoral approach, but outcomes appear similar. Manual thrombectomy limits distal embolisation and infarct size while drug-eluting stents reduce the need for further revascularisation procedures. Non-culprit disease is best dealt with electively as a staged procedure after primary PCI has been completed. The development of antithrombotic and antiplatelet regimens for primary PCI continues to evolve, with new indications for fondaparinux and bivalirudin as well as small-molecule glycoprotein (GP) IIb/IIIa inhibitors. If timely primary PCI is unavailable, fibrinolytic treatment remains an option but a strategy of early angiographic assessment is recommended for all patients. Non-ST segment elevation myocardial infarction (NSTEMI) is now the dominant phenotype and outcomes after the acute phase are significantly worse than for STEMI. Many patients with NSTEMI remain undertreated and there is a large body of recent work seeking to define the most effective antithrombotic and antiplatelet regimens for this group of patients. The benefits of early invasive treatment for most patients are not in dispute but optimal timing remains unresolved. Cardiac rehabilitation is recommended for all patients with acute myocardial infarction but take-up rates are disappointing. Home-based programmes are effective and may be more acceptable for many patients. Evidence for the benefits of lifestyle modification and pharmacotherapy for secondary prevention continues to accumulate but the argument for omega-3 fatty acid supplements is now hard to sustain following recent negative trials. Implantable cardioverter-defibrillators for patients with severe myocardial infarction protect against sudden death but for primary prevention should be based on left ventricular ejection fraction measurements late (around 40 days) after presentation, earlier deployment showing no mortality benefit.

Acute coronary syndromes

This overview highlights some recent advances in the epidemiology, diagnosis, risk stratification and treatment of acute coronary syndromes. The sheer volume of new studies reflects the robust state of global cardiovascular research but the focus here is on findings that are of most interest to the practising cardiologist. Incidence and mortality rates for myocardial infarction are in decline, probably owing to a combination of lifestyle changes, particularly smoking cessation, and improved pharmacological and interventional treatment. Troponins remain central for diagnosis and new high-sensitivity assays are further lowering detection thresholds and improving outcomes. The incremental diagnostic value of other circulating biomarkers remains unclear and for risk stratification simple clinical algorithms such as the GRACE score have proved more useful. Primary PCI with minimal treatment delay is the most effective reperfusion strategy in ST elevation myocardial infarction (STEMI). Radial access is associated with less bleeding than with the femoral approach, but outcomes appear similar. Manual thrombectomy limits distal embolisation and infarct size while drug-eluting stents reduce the need for further revascularisation procedures. Non-culprit disease is best dealt with electively as a staged procedure after primary PCI has been completed. The development of antithrombotic and antiplatelet regimens for primary PCI continues to evolve, with new indications for fondaparinux and bivalirudin as well as small-molecule glycoprotein (GP)IIb/IIIa inhibitors. If timely primary PCI is unavailable, fibrinolytic treatment remains an option but a strategy of early angiographic assessment is recommended for all patients. Non-ST segment elevation myocardial infarction (NSTEMI) is now the dominant phenotype and outcomes after the acute phase are significantly worse than for STEMI. Many patients with NSTEMI remain undertreated and there is a large body of recent work seeking to define the most effective antithrombotic and antiplatelet regimens for this group of patients. The benefits of early invasive treatment for most patients are not in dispute but optimal timing remains unresolved. Cardiac rehabilitation is recommended for all patients with acute myocardial infarction but take-up rates are disappointing. Home-based programmes are effective and may be more acceptable for many patients. Evidence for the benefits of lifestyle modification and pharmacotherapy for secondary prevention continues to accumulate but the argument for omega-3 fatty acid supplements is now hard to sustain following recent negative trials. Implantable cardioverter-defibrillators for patients with severe myocardial infarction protect against sudden death but for primary prevention should be based on left ventricular ejection fraction measurements late (around 40 days) after presentation, earlier deployment showing no mortality benefit.

Almanac 2011: Acute coronary syndromes. The national society journals present selected research that has driven recent advances in clinical cardiology

SUMMARY This overview highlights some recent advances in the epidemiology, diagnosis, risk stratification and treatment of acute coronary syndromes. The sheer volume of new studies reflects the robust state of global cardiovascular research but the focus here is on the findings that are of most interest to the practising cardiologist. Incidence and mortality rates for myocardial infarction are in decline, probably owing to a combination of lifestyle changes, particularly smoking cessation, and improved pharmacological and interventional treatment. Troponins remain central for diagnosis and new high-sensitivity assays are further lowering detection thresholds and improving outcomes. The incremental diagnostic value of other circulating biomarkers remains unclear and for risk stratification simple clinical algorithms such as the GRACE score have proved more useful. Primary PCI with minimal treatment delay is the most effective reperfusion strategy in ST elevation myocardial infarction (STEMI). Radial access is associated with less bleeding than with the femoral approach, but outcomes appear similar. Manual thrombectomy limits distal embolisation and infarct size while drug-eluting stents reduce the need for further revascularisation procedures. Non-culprit disease is best dealt with electively as a staged procedure after primary PCI has been completed. The development of antithrombotic and antiplatelet regimens for primary PCI continues to evolve, with new indications for fondaparinux and bivalirudin as well as small-molecule glycoprotein (GP) IIb/IIIa inhibitors. If timely primary PCI is unavailable, fibrinolytic treatment remains an option but a strategy of early angiographic assessment is recommended for all patients. Non-ST segment elevation myocardial infarction (NSTEMI) is now the dominant phenotype and outcomes after the acute phase are significantly worse than for STEMI. Many patients with NSTEMI remain undertreated and there is a large body of recent work seeking to define the most effective antithrombotic and antiplatelet regimens for this group of patients. The benefits of early invasive treatment for most patients are not in dispute but optimal timing remains unresolved. Cardiac rehabilitation is recommended for all patients with acute myocardial infarction but take-up rates are disappointing. Home-based programmes are effective and may be more acceptable for many patients. Evidence for the benefits of lifestyle modification and pharmacotherapy for secondary prevention continues to accumulate but the argument for omega-3 fatty acid supplements is now hard to sustain following recent negative trials. Implantable cardioverter-defibrillators for patients with severe myocardial infarction protect against sudden death but for primary prevention should be based on left ventricular ejection fraction measurements late (around 40 days) after presentation, earlier deployment showing no mortality benefit.

Almanac 2011: Acute Coronary Syndromes. The National Society Journals Present Selected Research that has Driven Recent Advances in Clinical Cardiology

This overview highlights some recent advances in the epidemiology, diagnosis, risk stratification and treatment of acute coronary syndromes. The sheer volume of new studies reflects the robust state of global cardiovascular research but the focus here is on findings that are of most interest to the practising cardiologist. Incidence and mortality rates for myocardial infarction are in decline, probably owing to a combination of lifestyle changes, particularly smoking cessation, and improved pharmacological and interventional treatment. Troponins remain central for diagnosis and new high-sensitivity assays are further lowering detection thresholds and improving outcomes. The incremental diagnostic value of other circulating biomarkers remains unclear and for risk stratification simple clinical algorithms such as the GRACE score have proved more useful. Primary PCI with minimal treatment delay is the most effective reperfusion strategy in ST elevation myocardial infarction (STEMI). Radial access is associated with less bleeding than with the femoral approach, but outcomes appear similar. Manual thrombectomy limits distal embolisation and infarct size while drug-eluting stents reduce the need for further revascularisation procedures. Non-culprit disease is best dealt with electively as a staged procedure after primary PCI has been completed. The development of antithrombotic and antiplatelet regimens for primary PCI continues to evolve, with new indications for fondaparinux and bivalirudin as well as small-molecule glycoprotein (GP)IIb/IIIa inhibitors. If timely primary PCI is unavailable, fibrinolytic treatment remains an option but a strategy of early angiographic assessment is recommended for all patients. Non-ST segment elevation myocardial infarction (NSTEMI) is now the dominant phenotype and outcomes after the acute phase are significantly worse than for STEMI. Many patients with NSTEMI remain undertreated and there is a large body of recent work seeking to define the most effective antithrombotic and antiplatelet regimens for this group of patients. The benefits of early invasive treatment for most patients are not in dispute but optimal timing remains unresolved. Cardiac rehabilitation is recommended for all patients with acute myocardial infarction but take-up rates are disappointing. Home-based programmes are effective and may be more acceptable for many patients. Evidence for the benefits of lifestyle modification and pharmacotherapy for secondary prevention continues to accumulate but the argument for omega-3 fatty acid supplements is now hard to sustain following recent negative trials. Implantable cardioverter-defibrillators for patients with severe myocardial infarction protect against sudden death but for primary prevention should be based on left ventricular ejection fraction measurements late (around 40 days) after presentation, earlier deployment showing no mortality benefit.

Secondary prevention for coronary artery disease: are we following the guidelines?

Secondary prevention pharmacotherapy in post-myocardial infarction (MI) patients reduces the risk of subsequent coronary events and overall mortality. International guidelines recommend use of aspirin, beta-blockers, ACE inhibitors and statins in post-MI patients. We performed this audit to review the compliance of prescribing practices, in a regional hospital in Ireland, with international guidelines for secondary prevention of coronary artery disease. We performed a retrospective case review of 172 patients diagnosed with MI during a 1-year period between January and December 2007. A total of 134 patients fulfilled the inclusion criteria. On discharge, aspirin was prescribed to 131 (97.76%) patients, clopidogrel to 126 (94%), beta-blockers to 117 (87%), ACE inhibitor to 87 (65%), ARB to 10 (7%) and statins to 116 (87%). Our audit shows that targets for prescription of secondary prevention medications were not met in a small but significant proportion of patients and calls for review of discharge practices and education to improve compliance with guidelines.

当院脳卒中センターにおけるＳＣＵの現状

Stroke unit (SU) with both stroke patient’s ward (or beds) and stroke team could significantly improve the outcome by decreasing mortality and increasing patients back to home with independent life in former clinical studies. In Japan, an additional payment to stroke care unit (SCU) which has the same definition as SU was introduced in public health insurance system from May, 2006. In our hospital, SCU with 6 beds and specific stroke team were organized in 2 acute patients wards composed with total 41 beds and registered from Jun, 2006. SCU was integrated with a special ward such as intensive care unit (ICU) with 14 beds for managing stroke patients with conscious disturbance or respiratory distress, IV thrombolytic therapy, and perioperative management of acute surgical or endovascular treatments. Main function of SCU was set up for acute physical rehabilitation, prevention of complications such as pneumonia, and pharmacotherapy for secondary prevention. From May, 2006 to Nov, 2008, 1,166 patients were managed in SCU. NIHSS of patients at admission was 6.3±7.0 in all stroke patients, 5.4±6.4 in patients with cerebral infarction, and 9.8±7.6 in patients with cerebral hemorrhage. Admitted period in SCU was 8.1±3.5 days in all patients, 8.1±3.6 days in patients with cerebral infarction, 8.3±3.2 days in patients with cerebral hemorrhage. Total admitted periods in hospital was 61.1±68.6 days in the first half of the investigation period (to July, 2007) and 52.5±51.8 days in the second half of the investigation period (from Aug, 2007). The outcome (mRS) at discharge was 56% in mRS 0–2, 40% in mRS 3–5, 4% in mRS 6 (death). In our stroke center, patients with mild to moderate severity were managed in SCU. After the introduction of SCU, shortening of total admitted periods in hospital and improving tendency of the outcome was observed. Stroke center equipped with SCU should be promptly organized nationwide corresponding to stroke emergency.